The Bristal Assisted Living Blog

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Discharge Planning: A Guide to a Smoother Transition

If you or a senior loved one is in the hospital or preparing for a scheduled surgery, planning for discharge is a vital part of the recovery process. Utilizing the right resources for follow-up care can be especially important in helping prevent older adults from being readmitted to the hospital.

Learn more about discharge planning and get tips on how you can adequately prepare. 

What is Discharge Planning?

Good discharge planning can help older adults experience a smoother transition to the next step of their recovery. Failing to plan can have the opposite effect, which could mean being readmitted to the hospital

Depending upon the health care system, discharge planning usually begins on the day of admission or even before, if surgery is planned beforehand.

Discharge planning involves numerous steps, including:

  1. Evaluation to ensure you are ready for discharge 
  2. Discussion between you and/or your representative and the hospital discharge planning team
  3. Reconciling medications to determine the right post-discharge meds are prescribed
  4. Planning to return home or transfer to a rehab center or long-term care community
  5. Determining the needs for caregiving or other support services
  6. Referrals to a home care agency and/or appropriate support organizations 
  7. Arranging for follow-up appointments or tests
  8. Explaining who to contact for questions or concerns post-discharge 

What Is a Care Coordinator?

Most hospitals have teams of discharge planners, nurse case managers, or social workers who help seniors plan for the next step of their recovery. While the title may differ depending upon the hospital, these care coordinators help you or your loved one plan for a smooth transition. 
They can act as the liaison between a skilled nursing community and the rehab center, or help track down specialty equipment if you are being discharged home. They will likely be your main point of contact with detailed information about your discharge plan, and they can serve as a valuable resource for any questions you may have. 

What Is the Role of the Caregiver in Discharge Planning?


As a caregiver or health care representative for a loved one, you might be called upon to provide insight into their discharge plan of care.

For example, a care coordinator may inquire about the following situations, including: 

  • The discharge planner or care coordinator might need your help understanding what an aging loved one with Alzheimer’s can still do independently and what they will need help with during recovery.
  • If your senior family member has a vision or hearing impairment that makes communication more difficult, you might be asked to provide medical history and other important information needed for your loved one’s recovery.
  • With your loved one’s permission, caregivers can also participate in selecting home health care or rehab providers, and attend any care conferences the hospital organizes to discuss the next steps.
Related: How to keep your loved one motivated for physical therapy >>


What Post-acute Care Options Are Available Under Medicare?

Depending upon your situation or that of your senior loved one, the next step in recovery can involve discharge to a short-term rehab center, going home with the support of home health care, or utilizing an outpatient rehab center. At least a portion of the costs for these services will be covered under Medicare with a qualifying hospital stay.

Short-term Rehab Center

If you or a loved one has been hospitalized at an inpatient level of care for at least three nights and their physician recommends a short-term rehab center, Medicare will pay for the first 20 days of care. For days 21 through 100, the individual will be responsible for a co-pay. Medicare does not pay for more than 100 days.

Related: Discover the benefits of physical therapy for seniors >>

Home Health Care

Some individuals opt to return home and use a home health care agency for skilled nursing and therapy services. If they are considered homebound as certified by their physician, Medicare will pay for all home health services. You or your loved one will be required to pay 20% of any necessary medical equipment.

Outpatient Rehab Centers

Individuals who choose to return home after a hospital stay and aren’t considered homebound and entitled to home health care can elect to receive outpatient therapy. After you pay your Medicare Part B deductible for the year, Medicare will pay for 80% of the Medicare-approved amount of your medically necessary outpatient therapy services. 

For more information on Medicare coverage, click here.

What Questions Should I Ask During Discharge Planning?

When you or the senior you are caring for is nearing the day of their discharge from the hospital, you may have many questions about what to expect next. Keep a list so you can be sure to have all of your concerns addressed before you leave the hospital.

Here are examples of key questions to get you started:

  • How long should you expect the recovery to last?
  • What can you look for that might indicate a problem?
  • Who do you call if questions or concerns come up after discharge?
  • When and who will review discharge instructions with you?
  • Are there any wound care or dressing changes you need to learn how to do?
  • What physician follow-up appointments will you need to schedule?
  • What is the contact information for specialists involved in your loved one’s care at the hospital?
  • What is the medication schedule and dosages?

Planning ahead can result in a better recovery and smoother transition back home or to a rehab center, whether you’re advocating for your own care needs or those of a senior loved one.

Interested in Learning More Tips for Caregiving?

Find tips and resources for caregivers in our blog articles on working with siblings in caregiver roles, communicating with your aging parent, and learning strategies as first-time caregivers.


This blog was originally published in 2018. It was updated in February 2024.



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